Aims: To evaluate the utilization of complementary and alternative medicine (CAM) in Kuching, Sarawak, Malaysia

Methods: This was a cross-sectional study of patients who attended three randomly selected primary care clinics over 4 months from January to April 2004. A total of 198 patients were recruited. One hundred and eighty-one (91.4%) patients agreed to participate by answering the anonymous questionnaire.

Results: Ninety (51.4%) patients used CAM of which 43 (47.8%) patients used more than one type of CAM. Utilization rates of CAM were found to be associated with employment status but not with other socio-demographic factors. The common types of alternative medicine used were massage (n = 63; 36.2%) and herbal medicine (n = 44; 25.1%). Forty-two (46%) of the CAM users, used CAM for the problems that led to their current clinic visit. Thirty-four (37.8%) were using alternative and modern medicine at the same time. The reasons for CAM usage given by about half of the patients were that CAM was more effective and better for emotional or mental health problems.

Conclusions: Usage of CAM was common in patients who visited primary care clinics. It is important to recognize this fact as combined use of CAM can create potentially dangerous interactions with pharmacotherapies

Key words: complementary and alternative medicine (CAM), primary care

Introduction

There is well-documented evidence that the use of complementary and alternative medicine (CAM) in Western society is high.1–3 A US survey in 1993 found that 34% of Americans were using at least one type of alternative therapy.1 In European countries, CAM was used by 20–50% of the population.3 An Australian survey in 1992/1993 found that 48.5% of the population used at least one non-medically prescribed alternative therapeutic modality.2 In studies in the US and Australia, CAM usage was found to be influenced by socio-demographic factors.1,2 However, little is known about the use of CAM in Malaysia.

The reasons patients are attracted to CAM may be related to the influence of the underlying philosophies they share, which involve nature, vitalism, “science” and spirituality.4 Austin et al. reported that besides patients’ perceptions that alternative therapies are more congruent with their philosophical orientation toward health, practitioners’ skills to listen, understand and deal with patients’ personal life as well as pathology, also play important roles.5

There are variations in the CAM methods used in various countries. Herbal medicines and spiritual healing are the two major types of CAM used in the Indian community in South Africa, while chiropractic is dominant in Australia and in the US.2,6,7

Malaysia is a multiracial and multicultural society, with an ethnic composition of Malays, Chinese, Indian and the indigenous groups in Sabah and Sarawak. The aim of this study is to learn about CAM utilization patterns in Kuching, Sarawak and the possible effects of different socio-demographic factors on these patterns.

Materials and methods

This was a cross-sectional study of patients attending three primary care clinics in Kuching. These clinics were selected by random sampling. The study proposal was approved by the ethics committee of the University Malaysia Sarawak. Patients, 15 years old and above, who attended any of these clinics were given a general questionnaire on socio-demographics and a questionnaire on CAM before they were seen by their primary care doctors. The researchers spent about 2 hours per week in each clinic over 4 months from January to April 2004. One hundred and ninety-eight patients were recruited for the study. Patients who were too ill, those below 15 years of age and those who came to the clinic to collect their medications were excluded from the study. Subsequent interviews were conducted only when the patient had consented to participate in the study.

One hundred and eighty-one patients (91.4%) agreed to answer the questionnaire and participate in the study (participants) and 17 patients (8.6%) refused (non-participants). Among the 17 non-participants, 15 agreed to provide only their socio-demographic details while two others totally refused to give any data.

The socio-demographic data collected included: gender, age, ethnic group, marital status, religion, employment status, education level and total family income. The questions on CAM included: usage of CAM in the past year, the type of CAM used, usage of CAM for the problem that led them to the clinic visit, usage of CAM before the visit, concurrent usage of CAM and modern medicine, any plans to use CAM in the future if not used before and reasons for using CAM.

The definition of CAM adopted in this study was: any treatments, self-help techniques or remedies, which are not normally provided by doctors and other healthcare professionals in the National Health Service. For the type of CAM used, respondents could choose from the following list of CAM practices: homeopathy, acupuncture, massage, herbal medicine, bomoh (Malay traditional healer), Chinese temple medium, aromatherapy and an open question on other remedies used. They could choose more than one type.

Analysis of data

Data collected was analyzed using Statistical Package for Social Science (SPSS). Unpaired Student’s t-tests were used to compare continuous variables; chi-squared test and Fisher’s exact test were used to test for differences between proportions. p < 0.05 was taken as the significance level.

Results

Profile of the project

For the demographic characteristics of the 181 patients, there were equal numbers of males and females. The majority of the patients were between 20 and 40 years old. There were almost equal numbers of Chinese (n = 64) and Malay (n = 72) patients, followed by Iban (n = 20), Bidayuh (n = 16) and other indigenous groups (n = 9). There was almost an equal number of married (n = 88) and single (n = 91) patients. Most of the patients were Muslim (45.9%) followed by Christian (30.9%), Buddhist (18.2%) and others (4.4%). More than half the patients (n = 107; 59.1%) were currently under full-time employment. Most of the patients (n = 121; 66.9%) had an upper secondary level of education and above. The mean total family income of the patients was RM 2540.91 (± 2179.74). The majority of them had a total family income of between RM 1000 to RM 3000(between US$270 to US$820).

Demographic data of the patients who used CAM

One hundred and seventy-five out of the 181 questionnaires were answered completely. Ninety (51.4%) patients who had completely answered the questionnaires used CAM over the past year. Table 1 compares the socio-demographic data of patients who used CAM and those who did not. There were significantly more patients on full-time employment and self-employment who used CAM compared to those who were never employed, currently unemployed or on part-time employment. There were no significant difference noted in gender, mean age, ethnic group, religion, marital status, education level and mean total family income between the two groups of patients.

Types of CAM used and relationship to ethnic groups

Nearly half the patients used more than one type of alternative medicine. There was no difference in the overall usage of CAM among the ethnic groups.

The common types of alternative medicine used were massage (n = 63; 36.2%) and herbal medicine (n = 44; 25.1%). The other types of CAM were not commonly used. The other remedies used were “berbekam” (using a heated glass tumbler to provide suction when applied to the skin), multivitamin supplements, relaxation and spa (see Fig. I for further details). There were more Malays who used massage compared to other ethnic groups (χ2 = 15.798, d.f. = 8, p = 0.045). There was no difference in the usage of other types of alternative medicine among the ethnic groups.

The concurrent use of modern medicine and CAM

Forty-two (46%) of the CAM users used alternative medicine for the problems that led them to the current visit to the clinic. The common problems mentioned were: musculoskeletal pain, fever, upper respiratory tract infection, chronic illness like diabetes mellitus and hypertension. Twenty-two (12.6%) were using CAM before this clinic visit. There were 34 (37.8%) who were using CAM and modern medicine at the same time. Thirty-eight (28.6%) of those who were not using CAM for the current problem would consider the use of CAM after the current clinic visit.

When asked about the reason for using CAM from the 90 patients who had used these methods over the past year, 45 (50%) used CAM because it was thought to be more effective; 42 (46.7%) said alternative medicine were better for emotional or mental health problems. Thirty-one (34.4%) patients thought it was better for physical illness; 23 (25.5%) said complementary and alternative medicine can help patients who were using modern medicine to improve faster. Only eight (8.9%) of the patients thought that the CAM practitioners understand the patient’s problem better than the modern doctors. The other reasons were: recommendation by relatives or friends, for relaxation, for emergency use or just to attempt to regain health.

Discussion

The study sample was not representative of the population of Sarawak but representative of Kuching city (capital of Sarawak) where most of the population were Chinese and Malays. The patients in this study were younger with a mean age of 35.87 years (total patient population mean age: 39.5 years) and from a higher education level where more than half (66.9%) had an education level of upper secondary and above (majority of total patient population had between lower and upper secondary level). The socio-economic background of the study population was above average with a mean total family income of RM 2540.91 (US$694.72). Average family income in general was RM 1000 (US$ 273) or below.

There was no significant difference in the gender, mean age, ethnic group, marital status, religion, education level and total family income for the patients who used CAM compared to those who did not use CAM. The finding with regard to CAM usage by gender is similar to the other primary care clinic-based studies.7,9 Other population-based studies found that female patients had a higher rate of CAM use.2,10 A possible reason could be that the population of patients who visited a primary care clinic were more likely to have chronic diseases and will more likely resort to alternative treatment regardless of their gender. Studies in America and Australia also found the highest use of CAM reported among those who were younger, better educated and had higher incomes.1,2 This was not shown in our study. Nevertheless, our study found that those patients who were currently on full-time employment or self-employment utilize CAM more than those who were currently unemployed or in part-time employment. A study in Australia also demonstrated similar findings.2 Employment and self-management were usually connected to income and education. There may be some confounding variables which need to be considered. This could be due to our study looking into total family income rather than individual income. Patients who are currently on full-time employment or self-employment could be more financially secure and could afford the cost spent on CAM in addition to the cost of visiting a private general practitioner.

The prevalence of CAM usage was high in this study where more than half (51.4%) of the patients had used CAM in the past year. This finding was similar to the findings by Elder et al. where they found a 50% CAM utilization rate among their primary care patients.7 Other studies in the USA1,11 Scotland12 Australia2 South Africa6 and Israel9 have reported the prevalence of CAM usage ranging from 19% to 48%. Some of these studies were community-based and some were done in primary care clinics. Although we could not find any significant difference in the age, education level and total family income among the user and non-user of CAM in this study, the high prevalence of CAM use in the study population could be due to the fact that the sample was taken from a group of younger patients with higher total family income and higher education level as shown in the demographic data of the overall patients who agreed to participate. In the other studies, patients who were younger, more educated and with higher household incomes were more likely to use CAM.1,2,9,11,12

There was no difference in overall CAM use among the different ethnic groups because in Malaysia, a multiracial and multicultural society, groups have their own cultural beliefs and traditional medical systems.13 In our study, the main types of CAM used were massage and herbal medicine. Massage is a type of alternative medicine commonly used by Malays as part of their traditional medical system and our study showed that more Malays were using massage compared to other ethnic groups. However, for herbal medicine, the different ethnic groups in Malaysia had their own form of herbal medicine so there was no significant difference in the usage of herbal medicine among them. For other types of CAM, the usage by the population in our study was too low to show differences between the ethnic groups. There was also variation in the CAM methods used by various countries. Herbal medicines and spiritual healing were the two major types of CAM used in the Indian community in South Africa6 while chiropractic was dominant in Australia2 and in the US.7

Our study found that almost 25% of patients who visited a primary care clinic used CAM for the problem that brought them to the clinics and almost half of these patients had tried CAM before they visited a primary care doctor. About half the patients who used CAM, used more than one method of CAM. However, the rate of concurrent use of CAM and modern medicine in our study was not as high as other studies such as in Scotland12 and South Africa6 where the reported concurrent use of both CAM and modern medicine were 48% and 50.7%, respectively. This could be due to under-reporting of their concurrent use because of the fear that the interviewer or the doctor would disapprove their usage. Usage of CAM and also concurrent use of CAM and conventional medicine is common among primary care attendees. Primary care doctors must bear in mind that their patients might have tried CAM or are using CAM in parallel with conventional medicine. Some forms of CAM, especially herbal medicine, may have adverse interactions with conventional medicine.14,15 A routine recording of CAM use in the medical history is recommended to allow a more integrated approach to patient care.12

The symptom-based nature of Western/allopathic medicine might be a drawback for patients who are interested in finding an explanation for their symptoms. People who were unhappy that the root cause of their problem is not being found, might try CAM as an alternative. In this study, the major reason given for CAM usage, cited by half the CAM users, was that it is more effective (both for emotional, mental and physical problems). Most of the patients thought that although modern medicine brought some improvement in their clinical conditions, it failed to cure the underlying problem.

In summary, we found that usage of CAM was common in patients who visited primary care clinics. It was important to recognize that combined use of CAM like herbal medicine can be dangerous, because case studies show that some types of CAM can create potentially dangerous adverse interactions with pharmacotherapies.14,16–19 For example, recent case reports suggest that mixing St. John’s wort with selective serotonin reuptake inhibitors can induce a mild serotonin syndrome17 In vitro studies also suggest that hypericum extracts are potent inducers of hepatic enzymes and are therefore capable of reducing the plasma concentrations of a variety of concomitant prescription medications, such as indinavir for patients with HIV.18,19

Summary of implications for GPs

The usage of CAM was common in patients who visited primary care clinics. Many patients did not report the use of CAM to their doctors.20,21 A primary care physician must be aware of the possible potentially dangerous adverse interactions of CAM and pharmachotherapies, hence discussion about CAM use with patients is useful to prevent adverse clinical effects.

Acknowledgments

This study was funded by the University Malaysia Sarawak short-term grant 01(81)/418/2003(155). The authors acknowledged the support given by the University. The authors also would like to thank Dr KS Yii, Dr Hazland Hipni, and Dr Norhayati Hassan for permission to conduct the study at their clinics. We would also like to thank Ms. Maimunah Razali, and Ms. Katijah Yaman, our research assistants for their untiring help in this study. We would extend our sincere gratitude to Mr Rekaya Vincent, a psychiatric male nurse for his contribution during the field work.